tci ED Coding & Reimbursement Alert - 2013 Issue 2

Reader Question: Don't Say Nope to the NOPP, Nature of the Presenting Problem Must be Considered

Question: I was recently dinged in an internal audit for coding too low for things like ankle sprain and toothaches when the documentation had a comprehensive history, comprehensive exam and moderate MDM (due to a prescription being given). How much should the presenting problem calculate into assigning the appropriate level of service? Oklahoma Subscriber Answer: The problem you mention is becoming more common. Physicians are documenting better now than ever before. As a result, selecting an ED E/M code is not as straightforward as an audit sheet makes it out to be. It is increasingly more important for an...

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